This article was downloaded by: [Florida State University] On: 05 October 2014, At: 13:47 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20

Professional nurses' views regarding stigma and discrimination in the care of HIV and AIDS patients in rural hospitals of the Limpopo province, South Africa a

b

a

Bumani S Manganye , Thelmah X Maluleke & Rachel T Lebese a

Department of Public Health, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa b

Human Sciences Research Council (HSRC), Private Bag X41, Pretoria 0001, South Africa Published online: 02 Sep 2013.

To cite this article: Bumani S Manganye, Thelmah X Maluleke & Rachel T Lebese (2013) Professional nurses' views regarding stigma and discrimination in the care of HIV and AIDS patients in rural hospitals of the Limpopo province, South Africa, African Journal of AIDS Research, 12:1, 33-40, DOI: 10.2989/16085906.2013.815411 To link to this article: http://dx.doi.org/10.2989/16085906.2013.815411

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

Copyright © NISC (Pty) Ltd

African Journal of AIDS Research 2013, 12(1): 33–40 Printed in South Africa — All rights reserved

AJAR

ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2013.815411

Professional nurses’ views regarding stigma and discrimination in the care of HIV and AIDS patients in rural hospitals of the Limpopo province, South Africa Bumani S Manganye1, Thelmah X Maluleke2* and Rachel T Lebese1 Department of Public Health, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa Human Sciences Research Council (HSRC), Private Bag X41, Pretoria 0001, South Africa *Corresponding author: e-mail: [email protected]

1

Downloaded by [Florida State University] at 13:47 05 October 2014

2

The aim of the study was to determine the views of professional nurses on the manifestations of HIV and AIDS stigma and discrimination and their influence on the quality of care rendered to people living with HIV and AIDS in three rural hospitals of Limpopo province, South Africa. The study was qualitative, exploratory, descriptive and contextual in nature. The population included all professional nurses registered with the South African Nursing Council who were working with confirmed HIV-positive patients in the three hospitals and had received specialised training in voluntary counselling and testing (VCT), antiretrovirals (ARV), prevention of mother-to-child transmission (PMTCT) and couple counselling. A purposive sampling method was used to select both the wards and participants, based on set criteria. A total of 9 wards (6 adult medical and 3 maternity) and 37 participants were selected. Focus group discussions and semi-structured and key informant interviews were conducted. Data were analysed using a combination of data analysis guidelines from different sources. Results revealed that professional nurses were aware of the existence of HIV and AIDS stigma and discrimination in their wards and regarded these as bad and improper care of HIV-positive patients. Behaviour included leaving care of HIV patients to junior members of staff with limited skills and knowledge of HIV and AIDS; showing HIV-positive patients that their disease was dangerous and contagious; judgmental behaviour towards and stereotyping of HIV-positive patients; and regarding patients with HIV and AIDS as uncooperative and problematic in the wards. Key words: attitude, discriminatory practices, judgemental behaviour, stigma, people living with HIV and AIDS, professional nurses, quality of care

Introduction Throughout the history of the human immune deficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic people living with HIV and AIDS (PLWHA) have been subjected to stigma and discriminatory practices in their homes, communities, workplaces and health care facilities. They continuously endure negative social labels of disgrace, prejudice, discounting, discrediting and rejection levelled at them. PLWHA are often blamed for contracting HIV, cursed and ostracised because of societal beliefs that having HIV and AIDS is a result of personal irresponsibility. This view is held by people who lack knowledge and understanding of the illness, and it often leads to judgemental behaviour and attitude towards the infected persons. Unfortunately, these societal views and judgemental attitudes and behaviours find their way into health care facilities leading to neglect and provision of inferior quality of care to PLWHA (Brown et al. 2001, Holzemer and Uys 2004, Kermode et al. 2005, Andrewin and Chien 2008, Wingood et al. 2008). Available evidence shows that stigma and discrimination exist in health care facilities and in the care of HIV-positive patients. These discriminatory behaviours by health care

workers have a negative influence on the quality of patient care provided to infected patients and the outcomes of HIV-prevention activities. Issues of patient neglect and maltreatment by the different categories of health care professionals and workers in hospitals have been reported. In some cases health professionals have refused or shown some reluctance to care for patients with AIDS (Boswarva 1991, Reeder et al. 1994). Stigma and discrimination levelled at PLWHA undermines all efforts made to fight the epidemic. It affects HIV test-seeking behaviour, care-seeking behaviour, quality of care given to patients and relationships between clients and caregivers (National Centre in HIV Research 2012). According to Sadoh et al. (2006) and Simbayi et al. (2007), stigma and discriminatory behaviours by health care workers have had a negative effect on the uptake of voluntary counselling and testing (VCT), the prevention of mother-to-child transmission (PMTCT) programme, disclosure of HIV status, acceptance and management of the illness and compliance with antiretroviral treatment. Professional nurses’ lack of knowledge about HIV and AIDS and fear of contracting HIV have been identified as the main causes of the HIV/AIDS stigma and discrimination in the health care setting. In a study by Katada (1994),

African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group

Downloaded by [Florida State University] at 13:47 05 October 2014

34

Manganye, Maluleke and Lebese

nurses involved in the care of PLWHA who expressed feelings of uneasiness were found to have inadequate knowledge of HIV and AIDS and how to take care of these patients. Similar views are expressed by Meiberg et al. (2008) who found that the main determinants of the HIV/ AIDS stigma in health care are the lack of knowledge about HIV and AIDS, fear of contracting HIV during care-giving, blaming PLWHA for their infection and associating HIV and AIDS with death. The challenge of fear of contracting HIV among nurses is that it contributes to their unhealthy attitudes towards HIV-positive patients, resulting in neglect and low quality care being given. Although Ncama and Uys (2003) acknowledge that the nurses’ fears could be well-founded, they argue that ethical, moral and professional responsibility should take precedence. Nurses have the responsibility to give proper and holistic care without discrimination and prejudice to all patients, including those who are HIV-positive. In a study by Kermode et al. (2005) health care workers expressed substantial concerns about their safety while providing care to HIV-positive patients. The perceived risk of occupational infection through needle pricks and contact with body fluids was found to be high. A similar view was expressed by Ndou (2005) who added that pregnant nurses expressed fears about the potential impact that HIV-related infections (especially the cytomegalovirus) could have on their unborn children if they were exposed to occupational risks like needle pricks. There is a close relationship between fears and perceptions, and fears and knowledge of HIV and AIDS, among health care workers. When the perceptions of health care workers are negative and their understanding of HIV and AIDS is inadequate, their fear of contracting HIV while caring for patients is high (Songwathana and Manderson 1998). South Africa, like many other countries, responded to the challenges related to the care of PLWHA by developing programmes and policies aimed at improving knowledge about HIV and AIDS among its citizens and health care workers. The aim was to prevent stigma and discrimination in health care facilities and communities. The government has introduced life orientation and life skills programmes in schools and higher education institutions. HIV and AIDS is a major feature of all curricula for health professionals. Through the HIV and AIDS and Sexually Transmitted Diseases in the Workplace programme, employers have been compelled to develop workplace policies to raise awareness of HIV and AIDS among their employees, ensure a better understanding of HIV and AIDS in the workplace, and prevent stigma and discrimination on the basis of HIV and AIDS status (Department of Health

2000). Given the above mentioned strategies and policies one would expect health care workers to be better prepared for the care of the HIV-positive patients. However, issues of HIV/AIDS stigma and discrimination in the community and health care services, and low quality of care in public hospitals continue to be reported in the media. Evidence exists that the availability of antiretroviral therapy (ART) has changed the perception of HIV and AIDS from a deadly disease to a manageable chronic disease, resulting in lowered stigmatisation and discrimination in high income countries and health services in urban areas. However, similar trends have not been observed in low income countries and rural areas. Patients in rural health facilities still report higher stigma and discriminatory practices than those in urban based health facilities (Peltzer and Ramlagan 2011). This article reports the results of a study which aimed to determine the views of professional nurses with specialised training on HIV and AIDS, working with confirmed HIV-positive patients on the manifestations of HIV/AIDS stigma and discrimination in the care of HIV and AIDS patients. Methods The study was conducted among professional nurses who had received specialised training related HIV/AIDS. The nurses were located at three rural hospitals in Limpopo province: one regional (Hospital A) and two district hospitals (Hospitals B and C). All three hospitals had HIV and AIDS clinics run and managed by a non-governmental organisation, or antiretroviral (ARV) sites where stable patients were seen. All nurses at these hospitals had received some basic training in HIV and AIDS, and some had specialised training related to HIV and AIDS patient care. Table 1 indicates the total number of professional nurses employed at the three hospitals and those who had received specialised training. A total of 185 (39.87%) of the professional nurses were trained in one or more HIV and AIDS related courses. The total 221 (47.63%) indicates the number of individuals who had attended different courses in the different hospitals. Table 1 shows that less than 50% of all professional nurses employed at the three hospitals had received specialised training in HIV and AIDS. In only one hospital more than half the professional nurses had received the specialised training. The trained professional nurses were distributed throughout the hospitals with most working in the HIV and AIDS designated clinics attached to the hospital.

Table 1: Professional nurses (P/N) who had received specialised training in some aspects of HIV and AIDS patient care

Hospital A B C Total

Total number of P/N 228 91 145 464

Trained individuals (head count) 93 31 61 185

% trained in each hospital 40.79 34.07 42.07

ARV 8 12 04 24

VCT 80 18 35 133

PMTCT

Couple counselling

% with special training based on the courses

13 13 26 52

05 03 04 12

46.49 50.55 47.59 47.63

African Journal of AIDS Research 2013, 12(1): 33–40

Downloaded by [Florida State University] at 13:47 05 October 2014

Research design This was a qualitative, exploratory, contextual and descriptive study. It aimed at exploring and describing the views of professional nurses with specialised training in HIV and AIDS on how stigma and discriminatory practices manifested themselves during the care of HIV and AIDS patients in the wards. Population The population in this study included all registered professional nurses working in the three hospitals who had received specialised training in any of the following: VCT, ARV, PMTCT and couple counselling. The reason for targeting this group was the assumption that specialised training in HIV prepares and equips nurses with the knowledge and skills necessary to care of HIV-positive patients and that their knowledge and skills would enable them to identify issues of HIV/AIDS stigma and discrimination in patient care. Any registered professional nurses working at the three hospitals who had received specialised training in VCT, ARV, PMTCT and couple counselling, but who was working on night duty or on leave did not form part of the study. Sampling Sampling of wards Purposive sampling was used to select the wards and professional nurses who participated in the study. A total of nine adult wards, six adult medical (one male and one female ward per hospital) and three maternity wards (one maternity ward per hospital) were selected. These wards were selected because this is where most confirmed HIV-positive patients are admitted and cared for. The other adult wards were excluded as they do not admit patients who need care that is directly linked to their HIV status. The researchers were aware that there could have been confirmed HIV-positive patients admitted to psychiatric or surgical wards, but as the main focus of their admission to the hospital was not HIV-related, these wards were excluded from the study. Sampling for focus group discussion Purposive sampling was used to select participants based on several criteria: the participants must be professional nurses working in medical or maternity wards and caring for HIV-positive patients; have at least one year’s experience working as professional nurses caring for HIV-positive patients; and have attended one or more HIV-related specialised training. The FGDs were conducted the nursing schools. The seating arrangements were consistent with FGD guidelines (Gilmore and Campbell 2005). Two questions were central to the discussion: ‘In what ways are HIV and AIDS stigma and discrimination manifested in your wards or units?’; and ‘What nursing care practices and attitudes do you consider to be HIV and AIDS stigma and discrimination related?’ Sampling for the key informant interviews Purposive sampling was used to select participants for the key informant interviews based on the criterion that they

35

must be professional nurses in charge of HIV and AIDS care and programmes. A total of six professional nurses in charge of HIV and AIDS care and programmes (two per hospital) were selected. Appointments were secured through deputy nursing managers at each hospital responsible for nursing care in the wards. A date and time were secured with each of the managers of the units. Semi-structured interview Purposive sampling was used to select participants for the semi-structured interviews based on the criterion that they must be operational managers in charge of HIV and AIDS care and programmes. Three (one from each hospital) operations managers were selected. The semi-structured interviews were conducted with operational managers. Appointments were secured through deputy nursing managers. A date and time was secured for interviews with each of the managers of the units. Data collection Thirty-seven professional nurses registered with the South African Nursing Council (SANC) who had received specialised training in VCT, ARV, PMTCT and couple counselling participated in the study; most (99.26%) were female. The reason for the low male participation could be that the nursing profession is still dominated by females and therefore fewer male professional nurses were available who suited the criteria used in the selection. The ages of participants ranged from 35 to 53 years. Three focus group discussions (FGDs) were conducted, one at each hospital. A total of 28 (Hospital A: 10, Hospital B: 6 and Hospital C: 12) professional nurses participated in the FGDs. Key informant interviews (two per hospital) were conducted with the professional nurses in charge of HIV and AIDS care and programmes. Semi-structured interviews were conducted with the operational managers, one at each hospital. With permission from the participants, an audio-recorder was used to record the discussion during FGDs and interviews. The researchers explained the purpose of the study before the discussions. The participants were informed that they were free to participate in the study and that they could withdraw from the study at any point (Burns and Grove 2001) without any penalty. No names would be used so that individuals would not be associated with the responses. All participants signed the consent forms before the interview started. No stipend or rewards were given for participation in the study. The researchers facilitated the FGDs in English, but participants were permitted to respond in their local languages. Data analysis The collected data were transcribed verbatim from the tape recordings, translated into English and analysed. A professional translator was used for the translation. A combination of data analysis guidelines from Maier et al. (1994), Tesch’s eight steps of qualitative data analysis (Cresswell 2003), and Streubert and Carpenter (1995) were used. Individual analysis of the transcriptions was done and categories were formed to allow the researchers to identify similarities,

Downloaded by [Florida State University] at 13:47 05 October 2014

36

differences and relationships. The developed categories were then grouped into themes. Furthermore, the services of a university professor in nursing with special training in HIV and AIDS as an independent coder were used to assist with the examination of the transcripts to ensure reliability. The categories developed by the independent coders were compared with those of the researchers. Categories that were similar were adopted; the differences were discussed and consensus reached. The analysis and findings were presented to the participants in a feedback workshop for their input and verification. The following procedure was used in data analysis. The researchers read through the transcripts carefully and noted the ideas that came to mind. The researchers then chose the most interesting transcript and read through it again to make sense of it and noted thoughts in the margin. A list of all the topics was made and similar topics were clustered and formed into columns that were arranged as major topics, unique topics and leftovers. The researchers then compared the list of topics to the data to ascertain that the topics developed were represented by the data. The different topics were abbreviated as codes which were written next to appropriate segments of the notebook to see whether new categories and codes emerged. The researchers found the most descriptive words for each topic and turned them into categories or sub-themes. Topics that related to each other were then grouped to reduce the number of categories and to create themes. Similar categories of data were grouped and analysed using Tesch’s method (Creswell 2003). Table 2 shows the categories and themes developed. Ethical considerations Before this research began, a research proposal was presented to the Higher Degrees Committee of the University of Venda. Once it had been approved, it was submitted to the University Ethics Committee for ethical clearance. The proposal was then submitted to the Department of Health and Welfare at provincial level for the Provincial Research Committee to approve. Permission to conduct the study was obtained from the Provincial Department of Health, Chief Executive Officer of the hospitals and operational managers of the wards. Anonymity of participants was maintained and assurance given that all information would be treated in absolute confidence. As the information collected could have some adverse outcomes for the hospitals and contributors, the names and districts where the hospitals are found have been withheld in this article. All data collected were safely stored and confidentiality was maintained. Results and discussions HIV/AIDS stigma and discrimination were regarded by the participants as the main causes of what they referred to as bad and improper care for patients living with HIV and AIDS. Participants regarded four practices that occurred in their wards as bad and improper care of HIV-positive patients and were viewed as manifestations of stigma and discriminatory practices in the wards. These included: leaving nursing care of HIV patients to junior members of

Manganye, Maluleke and Lebese

staff with limited skills and knowledge of HIV and AIDS; showing HIV-positive patients that their disease was dangerous and contagious; behaving judgmentally towards HIV-positive patients; and regarding patients with HIV and AIDS as being uncooperative and problematic in the wards. Holzemer and Uys (2004) identify three levels at which stigma and discrimination in health care facilities occur, namely direct person-to-person level, structural level and personal level. At direct person-to-person level, stigma and discrimination manifest through the following behaviours: blaming, rejecting, devaluing and excluding PLWHA during care giving. At the structural level, stigma and discrimination occurs when signs and designated clinical areas give away the diagnosis of the users, for example, the HIV clinic or ward or cubicles and colour-coded charts. At the personal level stigmatisation occurs when a person living with HIV/ AIDS applies the societal labels and lives accordingly. The stigma and discriminatory manifestations identified by the participants in this study are all related to the direct personto-person level. In other words, the participants might be unaware of the structural and personal level of stigma and discrimination. Leaving nursing care of HIV patients to junior members with limited nursing care skills and knowledge of HIV and AIDS Participants indicated that there was a tendency among senior staff members to ignore and avoid giving care to HIV-positive patients and leaving the nursing care of these patients to junior members with limited nursing skills and knowledge of HIV and AIDS. This practice was viewed as being improper and bad nursing, exacerbated by the HIV and AIDS stigma and discrimination. The quotes below indicate some of the unprofessional and unethical behaviours of some professional nurses who ignore patients needing their care and therefore exposing them to unnecessary suffering and complications. In one FGD a participant indicated: ‘Professional nurses sometimes do things that can make you doubt that they are nurses. If they know that the patient is positive, they will ignore the patient and send junior nurses to attend to the patient. You hear this person passing ‘snaaks’ (funny) remarks like “it is not me who said you must be sick, it was your promiscuous acts which gave you the disease” or insulting the patient. So, that is not good at all.’ One of the key informants in a maternity ward indicated: ‘According to my knowledge, some professional nurses do discriminate against HIV-positive patients. You can see this from the way they treat HIV-positive women. A woman coming to give birth being HIV-positive, they will treat her in a bad way. Also if the patient comes in being in labour they take the card and decode, if they see that the patient is positive, they disappear and won’t come back to the patient, they will dodge her until she is delivered by someone else, so that is discrimination and negative attitude.’ Similar findings have been indicated by Andrewin and Chein (2008) who found that about 10% of the health

African Journal of AIDS Research 2013, 12(1): 33–40

37

Table 2: Themes and categories developed

Downloaded by [Florida State University] at 13:47 05 October 2014

Theme Leaving nursing care of HIV patients to junior members with limited nursing care skills and knowledge of HIV and AIDS

Categories Labelling of and ignoring patient’s call for assistance due to their condition

Responses from FGD, key informant and semi-structured Frequencies - nurses still labelling or coding patient charts 4 - sending junior nurses to the patients 6 - senior nurses ignoring patient’s call 4 - keeping themselves busy when there is a positive patient calling for assistance 3

Allocating junior members to HIV patients

- dodge positive patients - care of HIV-positive patients always allocated to junior staff - not feeding HIV and patients/refuse to feed HIV-positive patients/feeding of HIV patients always allocated to junior nurses

1 4 3

Refusing to carry out required nursing care activities

- HIV patients made to wait for visiting hour for their families to feed them/HIV patients not fed food left on the bedside table until visiting hour for visitors to feed them - refusing or avoiding to take blood from HIV-positive patients - refusing to change dressings for HIV-positive patients - wearing more than one pair of gloves when bathing HIV-positive patients - wearing gloves when feeding HIV-positive patients

4

3 2 7 4

Showing HIV-positive patients that their disease is dangerous

Over usage of protective clothing HIV is a dangerous disease

- telling them that the disease is dangerous and it kills - wearing masks, gloves and gowns when going to the HIV cubicle - not spending time with the patient after a procedure - not chatting with patients during a procedure

3 1 2 2

Judgemental attitude towards HIV-positive patients

Judgemental remarks and behaviour

- making nasty comments/remarks - they should rather be discharged or die - they should be separated from other patients - blaming them for getting HIV - withholding patient treatment as a form of punishment for their ‘misbehaving’. - patients regarded as problematic and uncooperative - motivating for discharge of patient prematurely/deliberate - misinformation to the doctor to encourage patient discharge - view HIV-positive patients as outcasts

5 3 3 3 2 2 2 2 1

Forcing HIV-positive mothers to use formula feeding

- force mothers to use formula - mother not given information and choice on feeding method - taking away the right to decide/midwives deciding on feeding method for the patient - HIV patients often viewed as attention seekers - withdrawal of hand during blood taking viewed as uncooperative - confused HIV-positive patients labelled as uncooperative and problematic

4 2 2

- HIV-positive patients signing RHT told not to come back and not to go to any health facility in the country

1

Regarding patients with HIV and AIDS as being uncooperative and problematic in the wards

Deliberate misinterpretation of patient’s reaction Deliberate misinformation on Refusal of Hospital Treatment (RHT)

workers who participated in their study indicated that they avoided giving care to patients they suspected to be HIV-positive by passing the patients over and letting others deal with them. In some health care settings, health care workers have been known to leave patients in the corridors of hospitals, to refuse to give patients medical care and treatment or otherwise to give inferior treatment and to breach the patient’s confidentiality (UNICEF 2006). In Uganda denying patients access to medication, taking blood tests without the patients’ consent and lack of confidentiality were identified as key signs of stigmatisation and discriminatory practices within the health care system (Avert 2012). Refusal to give care or giving inferior quality of care to patients contravene the fundamental responsibility of a nurse as stipulated by the International Nursing

4 1 3

Council (ICN) and SANC, namely promoting, maintaining and restoring health and alleviating suffering (SANC). Furthermore, these behaviours contravene the undertakings in the Nurses’ pledge of service that requires nurses to put the needs of their patient first, hold in confidence all personal matters that their patients may disclose, not to discriminate against patients because of their social standing, and to respect the lives of all people. As these are the main pillars of the profession, it raises professional concern when they are completely disregarded or ignored. In support of ICN and SANC stipulations, nurses have an ethical and legal responsibility to provide quality and effective care to all their clients, including PLWHA, without stigma and discrimination (Anderson 2009).

Downloaded by [Florida State University] at 13:47 05 October 2014

38

Showing HIV-positive patients that their disease is contagious and dangerous Another practice viewed by the trained professional nurses as bad and improper care for HIV and AIDS patients, was showing HIV patients that their disease was contagious and dangerous. The manifestation of this practice were nurses wearing more than one pair of gloves, masks and other protective clothing at all times, including when giving oral medication and feeding patients. One participant in the FGD indicated: ‘It is difficult to deal with the problem of wearing protective clothing and the message it sends to the patient. You find yourself lacking an answer when you ask them why they wear so many gloves especially when they are going to the AIDS cubicle. When you ask and a staff member says to you, “AIDS kills! I see this everyday in this very ward. I must protect myself I don’t want to die too.” What can you do? Absolutely nothing.’ This view suggests that the fear of contagion and death leads to over usage of the protective clothing by some professional nurses, and this dehumanises patients. Although the participant was unhappy with this behaviour, she/he felt disempowered to take action to prevent it. A study by Daniel et al. (2004) found that fear of contagion was high among care providers. That fear also tended to increase as contact with AIDS patients increased, despite improved knowledge and experience. The study by Mahendra et al. (2007) suggests that people who have higher stigma levels behave in a discriminatory manner and will probably avoid any contact with HIV-infected patients. An interesting observation made during this study was that all the hospitals had designated clinics, wards and cubicles for HIV-positive patients. However, none of the participants mentioned this as a form of stigmatisation and discrimination against PLWHA. The separate wards gave away the diagnosis of the patients, as in many cases in their discussions they referred to them as ‘AIDS wards or cubicles’. The previous quote also shows that the participant did not see this arrangement as stigmatisation and discriminatory practices against PLWHA, her/his problem was mainly the manner in which staff members were wearing their protective clothing. The inability to realise structural stigmatisation and discriminatory practices raises the question whether the training received by these participants had addressed issues of stigma and discrimination. Judgmental attitude and behaviour towards HIV-positive patients Judgmental attitudes and behaviour that were mentioned by participants were: refusing to collect or avoiding collecting blood specimens from HIV-positive patients by some professional nurses; blaming HIV-positive patients for having the disease; and forcing HIV-positive mothers to use formula feeding. Participants during key informant interviews indicated that some professional nurses in the wards openly displayed their judgmental attitudes and behaviour towards HIV-positive patients. They blamed PLWHA for contracting the disease and saw the disease as punishment for their bad behaviour; PLWHA therefore did not deserve care,

Manganye, Maluleke and Lebese

sympathy and love. As one key informant indicated: ‘They refused to carry out some of their nursing duties with HIV patients, for example, by refusing to collect or avoiding collecting blood specimens from them. They blame patients for having the disease and passed derogatory or mean remarks. They see HIV-positive patients as outcasts and therefore treat them in the same way. They label HIV-positive patients as being problematic and even suggest to doctors that they should be discharged or separated from other patients as a form of punishment for their bad behaviour.’ A study by Mulaudzi et al. (2011) had similar findings where some nurses exhibited stigmatising attitudes and non-caring behaviours towards PLWHA. These nurses preferred separate wards, bathroom and eating utensils for HIV and AIDS patients. They blamed patients for their HIV status and patients were seen to be responsible for their disease because of immoral and deviant behaviours. When they were asked to give examples of what the nurses regarded as bad behaviour that HIV patients should be punished for, one participant said: ‘There is no bad behaviour here. These people just have a negative attitude. You know it is normal that some patients will withdraw their hand when they are pricked, same happens with HIV-positive patients. But if an HIV-positive patient withdraws or moves his/her hand when nurses are taking blood they are regarded as problematic, you see. A person will go to an extent of influencing the doctor to discharge the patient. This is not good nursing care.. According to National Centre in HIV Research (2012) judgemental attitudes and lack of confidentiality are common in rural health care settings due to lack of knowledge on HIV and confidentiality. The Centre further argues that confidentiality is compromised in rural health care settings because of lack of anonymity as nurses and patients often know each other. This has an impact on the health seeking behaviour of local communities, as they find it difficult to use clinics where they are familiar with the nurses. This situation forces PLWHA to seek health care services in facilities that are outside their communities. Accessing health facilities that are further away from their homes becomes a challenge due to transport costs and often results in treatment interruptions and defaults. These findings are similar to some of the eight examples of stigmatisation attitudes, behaviour and actions in health care settings identified by EngenderHealth (2004) which are: discharging patients because of their HIV status; disregarding the seriousness of their condition; blaming the patient for becoming infected,; keeping HIV-positive patients in their own ward or section of the ward as a condition for providing services; low quality of care given to PLWHA, disclosing the patient’s status, demanding compulsory HIV testing as a condition of providing services; and refusing to give treatment or care to HIV-positive patients. Similarly Mahendra et al. (2006) identified the following as manifestations of stigma and discrimination in the health setting: passing judgemental remarks; unnecessary referral of AIDS patients to other facilities; refusing to give care and

Downloaded by [Florida State University] at 13:47 05 October 2014

African Journal of AIDS Research 2013, 12(1): 33–40

39

treatment or to perform a procedure on the patient; labelling HIV patients as being problematic; extreme use of protective clothing; having a separate ward or section of the ward designated for HIV patients; testing patients for HIV without their consent; failure to provide pre- and post-test counselling; withholding HIV test results from the patient; disclosing the patient’s HIV status without his/her consent; and lack of institutional policies to protect. Mahendra et al. (2006) argue that both the institution and individuals tasked with the provision of care to PLWHA are the perpetrators of stigma and discrimination in a health setting.

study. Those who were on leave, off-duty or were on night duty were not able to participate in FGDs. Another limitation was the continuous need to reschedule meetings for the data collection process, as professional nurses were busy attending to patients and could not attend the scheduled meetings. This situation compelled the researchers to conduct only one FGD per hospital and only on a Wednesday, which was the day when all professional nurses in the wards were at work.

Forcing HIV-positive mothers to use formula feeding Participants indicated that in maternity wards some professional nurses forced mothers who were HIV-positive to use formula feeding instead of breast milk because the nurses believed the infection could be transferred from mother to child through breast milk. This was viewed as disempowering to the mother because it took away her right to decide. One participant said: ‘Sometimes you find them also forcing patient to use formula feeding, even if the mother wants to breast feed, because they think the child will get infection in breast milk. They don’t know much about it.’ Forcing a mother to use formula feeding is against the World Health Organization guidelines that allow mothers known to be HIV-infected to choose to breastfeed their infants for the first six months. The guidelines also require the health care worker to first establish if it will be feasible for the baby to use formula feeding. Before putting a baby on formula, the health care worker must assess the mother’s background with regard to the availability of safe water and sanitation, her ability to provide sufficient infant formula, her ability to prepare formula that is safe for the child, and whether formula feeding will be supported by the family (WHO 2010).

This article has highlighted the views of professional nurses who had specialised training in HIV and AIDS regarding the manifestation of stigma and discriminatory practices in the care of HIV and AIDS patients in three rural hospitals of Limpopo province. Rural HIV patients still suffer stigmatisation and discrimination at the hands of their health care providers. HIV and AIDS stigma and discrimination occur at all levels, direct person-to-person, structural and personal levels. However, professional nurses trained in specialised areas of HIV and AIDS only raised direct person-to-person manifestations. This raises a concern that stigma and discriminatory practices occurring at structural and personal levels go unnoticed and will therefore not be addressed. The consequences of the HIV/AIDS stigma and discriminatory practices are that the quality of nursing care given to HIV and AIDS patients in these rural hospitals will continue to be compromised.

Recommendations To deal with the HIV and AIDS stigma in the ward situation all professional nurses should be trained and regular in-service education provided to ensure that professional nurses’ knowledge remains at the highest possible level. The management of the wards or units should create awareness among staff members about new practices, available HIV and AIDS policies and how these policies should be implemented in the ward situation. Support systems should be developed for the nurses on issues related to HIV and AIDS so they can share their experiences and challenges in the care of PLWHA. Study limitations The study only included professional nurses who had specialised HIV training in three rural hospitals from one district of the Limpopo province. The views of other professional nurses and other categories they were reporting were not tapped. Only the professional nurses who had specialised HIV training and were on duty during the data collection period and willing to participate took part in the

Conclusion

The authors — Bumani Manganye is a registered nurse currently working as an Operational Manager Primary Health Care at Nghezimani clinic and Sub-District Mental Health Co-ordinator in the Vhembe District Municipality, Limpopo Province of South Africa. He holds an MPH (Health Policy and Management) degree from the University of Venda, South Africa. Thelmah Maluleke is currently working for the Human Sciences Research Council–Population Health, Health Systems and Innovation as a Senior Research Manager in the Pretoria Office. She holds an MSc (International Health) from QMC- Edinburgh and Doctor of Literature and Philosophy from UNISA. She has supervised master’s dissertations and promoted and co-promoted doctoral theses. Her research work and publications are in the area of sexual health, HIV and AIDS, health promotion, gender and indigenous knowledge systems. She has authored a book on sexual health and book chapters in five Life Orientation books for FET colleges. Rachel Lebese is currently working as a senior lecturer at the University of Venda. She holds an MCur and DCur from the University of Venda. She has supervised master’s dissertations and has co-supervised PhD theses. Her research and publication are in the area of sexual health with special emphasis on adolescent health, HIV and AIDS and indigenous knowledge systems.

References Anderson BJ. 2009. HIV stigma and discrimination persist, even in health care. Virtual Mentor 11: 998–1001. Andrewin A, Chien L. 2008. Stigmatization of patients with HIV/ AIDS among doctors and nurses in Belize. AIDS Patient Care and STDs 22: 897–906. Avert. 2012. HIV & AIDS stigma and discrimination. Available at http:// www.avert.org/hiv-aids-stigma.htm [accessed 3 December 2012].

Downloaded by [Florida State University] at 13:47 05 October 2014

40

Boswarva P. 1991. Attitudes and responsibilities of nurses towards the HIV seropositive client: A literature review. Nursing Monograph Journal 10: 289–295. Brown L, Trujillo L, Macintyre K. 2001. Interventions to reduce HIV/ AIDS stigma: What have we learned. New York: Horizons-The Population Council. Burns N, Grove S. 2001. The practice of nursing research: conduct, critique and utilization. Philadelphia: WB Saunders. Creswell JW. 2003. Research design: Qualitative and quantitative approach. London: Sage. Daniel N, Machado PF, Sala MA, Komesu MC. 2004. Attitudes of dental students and dental professionals caring for HIV-positive patients in Sao Paulo, Brazil. AIDS Patient Care and STDs 18: 63–65. Department of Health. 2000. HIV/AIDS/STD strategic plan for South Africa, 2000–2005. Available at http://www.info.gov.za/ otherdocs/2000/aidsplan2000.pdf [accessed 15 January 2011]. Engenderhealth. 2004. Reducing stigma and discrimination related to HIV and AIDS training for health care workers. Trainer’s manual. EngenderHealth: New York. Available at: http://www. rhrc.org/resources/sti/hivaidsmanual/resources/from-web/ stigma_trainer.pdf [accessed 13 March 2011]. Holzemer WL, Uys LR. 2004. Managing AIDS stigma. Journal of Social Aspects of HIV/AIDS 1: 166–174. Gilmore GD, Campbell MD. 2005. Needs and capacity assessment strategies for health education and health promotion. Sundburry: Jones and Bartlett Publishers. Katada N. 1994. Japanese nurses’ perception towards HIV and AIDS patient care. International conference on AIDS 10: 7–12. Kikwawila Study Group. 1994. Qualitative research methods: Teaching materials from a TDR Workshop. UNDP/World Bank/ WHO Special Programme for Research and Training in Tropical Diseases (TDR). Available at http://www.who.int/tdr/publications/ documents/qualitative-research.pdf [accessed 14 March 2011]. Kermode M, Holmes W, Langkham B, Thomas MS, Gifford S. 2005. HIV-related knowledge, attitudes and risk perception amongst nurses, doctors and other healthcare workers in rural India. Indian Journal of Medical Research 122: 258–264. Mahendra VS, Gilborn L, Bharat S, Mudoi R, Gupta I, Goerge B, Samson L, Dally C, Pulerwitz J. 2007. Understanding and measuring AIDS related stigma in health care settings: A developing country perspective. Journal of Social Aspects of HIV and AIDS 4: 617–625. Maier B, Gorgen R, Kielmann AA, Diesfeld HJ, Korte R. 1994. Assessment of the district health system using qualitative methods. London: Macmillan Press Ltd. Meiberg AE, Bos AER, Onya HE, Schaalma HP. 2008. Fear of stigmatization as barrier to voluntary counselling and testing in South Africa. East African Journal of Public Health 5: 49–54. Mulaudzi VM, Pengpid S, Peltzer K. 2011. Nurses knowledge, attitudes, and coping related to HIV and AIDS in a rural hospital in South Africa. Studies on Ethno-Medicine 5: 25–32. Available at http://www.krepublishers.com/02-Journals/S-EM/EM-05-0000-11-Web/EM-05-1-000-11-Abst-PDF/EM-05-1-025-11170-Mulaudzi-M-V/EM-05-1-025-11-170-Mulaudzi-M-V-Tt.pdf [accessed 4 December 2012].

Manganye, Maluleke and Lebese

Gilmore GD, Campbell MD. 2005. Needs and capacity assessment strategies for health education and health promotion (3rd edn). Sundburry: Jones and Bartlett Publishers. Mahendra VS, Gilborn L, George B, Samson L, Mudoi R, Jadav S, Gupta I, Bharat S, Daly C. 2006. Reducing AIDS-related stigma and discrimination in Indian hospitals. Horizons Final Report. New Delhi: Population Council. National Centre in HIV Research. 2012. Stigma and discrimination around HIV and HCV in Healthcare Settings: Research report. ASHM & NCHSR. Available at http://www.ashm.org. au/Publications/Stigma_and_Discrimination.pdf [accessed 4 December 2012]. Ncama BP, Uys LR. 2003. Exploring the fear of contracting HIV/ AIDS among trauma nurses in the Province of KwaZulu-Natal. Curationis 26: 11–18. Ndou ND. 2005. Registered nurses’ experiences of working in a high-risk environment for contracting HIV and AIDS. Masters dissertation, University of South Africa, Pretoria. Peltzer K, Ramlagan S. 2011. Perceived stigma among patients receiving antiretroviral therapy: a prospective study in KwaZulu-Natal, South Africa. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 23: 60–68, DOI: 10.1080/09540121.2010.498864. Reeder JM, Hamblet JL, Killen AR, King CA, Uburu A. 1994. Nurses’ knowledge, attitudes about HIV, AIDS. A replication study. Association of periOperative Registered Nurses Journal 9: 450–466. Sadoh AE, Fawole AO, Sadoh WE, Oladimeji AO, Sotiloye OS. 2006. Attitude of health-care workers to HIV/AIDS. African Journal of Reproductive Health 10: 39–46. Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. 2007. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Social Science & Medicine 64: 1823–1831. Songwathana P, Manderson L. 1998. Perceptions of HIV/AIDS and caring for people with terminal AIDS in Southern Thailand. AIDS Care 18: 155–165. Streubert HJ, Carpenter DR. 1995. Qualitative research in nursing: Advancing the humanistic imperative. Philadelphia: J.B. Lippincott Company. UNICEF (United Nations Children’s Fund). 2006. Stigma, HIV and AIDS and prevention of mother-to-child transmission- a pilot study conducted in Zambia, India, Ukraine and Burkina Faso. Available at www.unicef.org/aids/aids-panosreportBS.pdf [accessed 23 July 2011]. Wingood GM, Reddy P, Peterson SH, DiClemente RJ, Nogoduka C, Braxton N, MBewu AD. 2008. HIV stigma and mental health status among women living with HIV in the Eastern Cape, South Africa. South African Journal of Science 104: 237–240. WHO (World Health Organization). 2010. Guidelines on HIV and infant feeding 2010: principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Available at http://whqlibdoc.who.int/ publications/2010/9789241599535_eng.pdf [accessed 15 January 2011].

Professional nurses' views regarding stigma and discrimination in the care of HIV and AIDS patients in rural hospitals of the Limpopo province, South Africa.

The aim of the study was to determine the views of professional nurses on the manifestations of HIV and AIDS stigma and discrimination and their influ...
224KB Sizes 0 Downloads 12 Views